FOR INTERNAL EMERGENCIES

Royal Children s Hospital INTERNAL EMERGENCY RESPONSE PLAN FOR INTERNAL EMERGENCIES DIAL 55

TABLE OF CONTENTS SECTION 1: CONTENTS AND EMERGENCY RESOURCES 5 Amendments 5 Related Links 6 SECTION 2: INTRODUCTION 7 Forward 7 Internal Emergencies 7 Chemical Biological Radiological (CBR) Incidents 7 Colour Codes for Emergency Identification 8 Initial Notification 8 Authority during an Emergency 8 Media Control 9 SECTION 3: ACTIVATION 10 Stages of Activation 10 Command Post 11 Alternative Command Post 11 Cancellation of Code 11 Debrief 12 Occupational Health and Safety Requirements 12 SECTION 4: INTERNAL EMERGENCY (CODE YELLOW) 13 Explanation 13 Principles of Emergency Response 13 General Service Failure 14 Hazardous Materials Incident 14 Strutural Damage 14 Staff Obligations Internal Emergency 15 Pedestrian Evacuation Traffic 16 Pedestrian Non-Evacuation Traffic 16 Vehicular Traffic 16 Removal of Vehicles 16 Illegal Occupancy 16 Emergency Call Out List 17 SECTION 5: EVACUATION (CODE ORANGE) 18 Progressive Evacuation of the Building 18 Explanation 18 Assessing the Situation 18 Authority to Evacuate 19 Version 1.0 June 2007 Page 2 of 53

Stages in Evacuation 19 Egress Routes 19 Lifts 19 Evacuation of Personnel and Patients 20 Assembly Areas 20 Room Check / Record Collection 20 Fire Exit Monitors 20 Factors for Consideration 20 Ambulatory Patients 21 Wheelchair Patients 21 Non-Ambulatory Patients 21 Patient Care Following Evacuation 21 General 21 Sister Wards 22 Emergency Call Out List 23 SECTION 6: FIRE (CODE RED) 24 Explanation 24 Reporting a Fire 24 Action in the event of a Fire Alarm Activation 25 Action on discovery of a Fire 25 Fire Fighting Equipment 25 Fire Extinguishers 25 Fire Blankets 26 Emergency Call Out List 27 SECTION 7: BOMB / ARSON THREAT (CODE PURPLE) 28 Introduction 28 Threat - Types 28 Bomb Threat Receipt Checklist 29 Bomb / Arson Threat Search Checklist 30 Roles and Responsibilities 31 General Responsibilities 31 Search 31 Evacuation 32 Search without Evacuation 32 Evacuation and Search 32 Partial Evacuation 32 Safety Factors 33 Search after Evacuation 33 Emergency Call Out List 34 Version 1.0 June 2007 Page 3 of 53

SECTION 8: PERSONAL THREAT (CODE BLACK) 35 Armed or Unarmed Persons Threatening Injury to others or themselves 35 Armed Confrontation 35 Drug Hold Ups 35 Threatening and Nuisance telephone Calls 36 Armed Hold Up 36 Cash Hold Up 36 Hostage 36 Irrational Person 37 Personal Threat Receipt Checklist 38 Emergency Call Out List 39 SECTION 9: ROLE DESCRIPTION TABLE 40 Emergency Call Out List 40 Command Group 41 Support Call out Staff 41 Emergency Contact telephone Numbers 42 COMMAND POST COORDINATOR 43 COMMAND POST OFFICER 43 NURSING ACTIVITIES COORDINATOR 44 OPERATIONAL SUPPORT SERVICES COORDINATOR 45 INPATIENT MOVEMENT COORDINATOR 46 SECURITY SERVICES COORDINATOR 47 MEDIA AND PUBLIC AFFAIRS COORDINATOR 48 OCCUPATIONAL HEALTH & SAFETY COORDINATOR 49 BUILDING COORDINATOR 50 INFORMATION TECHNOLOGY COORDINATOR 51 SECTION 10: SITE PLAN 52 Version 1.0 June 2007 Page 4 of 53

SECTION 1: CONTENTS AND EMERGENCY RESOURCES Amendments This emergency plan was initially prepared in January 2004 and recently updated in April 2007. Sections of this plan will be revised in accordance with changes to standards or other external factors. The emergency plan will be revised dependant on updates and changes in process. The dates of revision and sections amended will be documented on this page. 1. Proposed amendments to this plan are to be forwarded to:- Occupational Health and Safety Unit Royal Children s Hospital and Health Service District Telephone: (07) 3636 8164 Facsimile: (07) 3257 1768 2. Amendments to this plan must be inserted into the plan as distributed, with the responsible officer certifying the amendment inclusion. Amendment Number Amendment Date Sections Amended Signature Date Version 1.0 June 2007 Page 5 of 53

Related Links Australia s Biosecurity health Response http://www.health.gov.au/pubhlth/strateg/bio/index.htm This website is designed to provide information about the response by Australia s health authorities to the threat of the release of a chemical or biological agent in Australia. Emergency Health Services Health Unit http://qheps/emerg_serv/home.htm Located in Corporate Office, this Unit provides the principal liaison point for the State s emergency services and for Co-ordination of the Department s advice on emergency health matters. Emergency Management Australia http://www.ema.gov.au/ EMA provides national leadership in the development of measures to reduce risk to communities and manage consequences of disasters. Queensland Counter Disaster and Rescue Services (CDRS) http://www.emergency.qld.gov.au/cdrs/ CDRS is responsible for Queensland s disaster management arrangements. Centre for Disease Control and Prevention (CDC) http://www.bt.cdc.gov/ http://www.bt.cdc.gov/index.asp CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. National Security Australia http://nationalsecurity.ag.gov.au/ National security embraces measures to protect the Australian community, government and institutions from harm. This website provides a single access point for national security information from the Australian Government. Department of Emergency Services http://www.emergency.qld.gov.au/cdrs/ Version 1.0 June 2007 Page 6 of 53

SECTION 2: INTRODUCTION Forward The following Internal Emergency Response Plan has been complied by the Safe Practice and Environment Committee to ensure that the emergency response measures for the Royal Children s Hospital are properly coordinated and integrated. All management and staff have an obligation towards the implementation and maintenance of safe working practices, through the observance of laid down safety procedures. These procedures are designed to provide guidelines and directions for a safe coordination to an actual or imminent on-site emergency. All staff are to be aware of their roles and responsibilities in the event of such an emergency. It should be noted that procedures in isolation will not necessarily ensure the correct action by staff during an emergency response; staff must also actively participate in specialized training programs and exercises provided by the District. Internal Emergencies Internal emergencies are any incidents that threaten the safety of the physical structure of the hospital, staff, patients and visitors. Internal emergencies may also reduce the capacity of the hospital to function normally. In most cases staff in departments and units will be responsible for their own internal response. All staff will receive appropriate training to fulfill their roles in dealing with these emergencies. Chemical Biological Radiological (CBR) Incidents Health Care facilities may be the initial site and recognition and response to CBR incidents. If a CBR event is suspected, local emergency response systems should be activated. Should a release, or threatened release, of a chemical, biological or radiological agent be the result of a terrorist or criminally instigated action, the Queensland Police Service will be the controlling / coordinating authority for the response by all agencies. The procedure outlined in the State CBR Plan will complement arrangements and legislation. For more information refer to the listed address. http://qheps/emerg_serv/emergency/documents.htm Version 1.0 June 2007 Page 7 of 53

Colour Codes for Emergency Identification To facilitate identification of and communication about the various types of emergencies, the following colour codes have been developed. The colour codes are based on Australian Standard 4083-1997 Emergency Response for Health Care Facilities. Code BLUE Code Yellow Code Orange Code Red Code Purple Code Black Code Brown Medical Emergency Internal Emergency Evacuation Fire/Smoke Bomb Threat Personal Threat External Emergency Initial Notification The initial notification of an emergency situation and status will be made to switchboard Services. Switchboard Services shall record: Time of call; Circumstances of events, e.g. service failure; Name, position and phone number of informant. If there is any doubt that the call is valid, the informant will be immediately phoned back for confirmation of the details of the event. Authority during an Emergency The established hierarchy, already applying to normal work related activity, will generally apply during an emergency; some areas will have nominated emergency officers (Floor and Fire Wardens). Supervisors/Line Managers and Wardens will provide the initial control, with subsequent guidance and assistance from specialist hospital staff, e.g. Safety and Security Officers, Manager Operational Services and the Manager Occupational Health and Safety. On the arrival of the external Fire and Emergency Services (QFRS), the senior officer in attendance will assume the role of Incident Commander or Chief Warden. However, there will continue to be considerable reliance on effective interaction between on site specialist staff and the emergency services. Version 1.0 June 2007 Page 8 of 53

Media Control Any major emergency affecting the Royal Children s Hospital is likely to attract the attention of the media. All staff are to be aware of the importance of ensuring that all Media interest is properly channeled through the Public Affairs Department, Royal Children's Hospital and Health Service District. So that the hospital is represented with informed responses to media questioning, all enquiries must only be handled by the following: Public Affairs Department District Manager Executive Member Nominated (by Executive) hospital representative Media representatives will be asked to assemble in the following areas or as otherwise required depending on the nature of the emergency. Area Affected Surgical Building - Emergency Woolworths Medical Building - Emergency Coles Services Building - Emergency RCH Foundation Building Emergency Lady Norman Wing Building C28 Leonard Lodge Media Conference Assembly Area Auditorium - Education Centre, Level 5 Woolworths Medical Building. Foyer RCH Foundation Building. Foyer RCH Foundation Building. Auditorium - Education Centre, Level 5 Woolworths Medical Building. Auditorium - Education Centre, Level 5 Woolworths Medical Building. Auditorium - Education Centre, Level 5 Woolworths Medical Building. Auditorium - Education Centre, Level 5 Woolworths Medical Building. Version 1.0 June 2007 Page 9 of 53

SECTION 3: ACTIVATION Stages of Activation In an emergency, senior management staff or Protective Services shall make an assessment of the emergency and advise the Switchboard Services Operator of one of the recognized stages of activation. Depending on the type of emergency, they will determine if the response needs to be elevated to a higher level and whether or not to establish a command post. After a full response, from stage 1 to 4, the District Manager and/or Executive Director Corporate Services will coordinate a major debriefing session with the Command Group and relevant Department / Managers. Stage 1 ALERT Emergency notified. Senior management have been notified of a situation that could escalate or which may require the coordination of resources and support. Stage 2 STANDBY There is an increased likelihood that the emergency situations will have a major impact on services. Stage 3 CALL OUT Emergency situation exists. On receipt that a major incident / disaster has occurred and there is a requirement for the Command Group to be notified. Stage 4 STAND DOWN Emergency is contained and operations are no longer required. The hospital shall resume normal activities and debriefing. Version 1.0 June 2007 Page 10 of 53

Command Post For major emergencies, the Command Post will be established in the Department of Emergency Medicine, Resources Work Room, Ground Floor (Surgical Building). The conference room will contain: Telephone services on dedicated outside lines to facilitate communication in the event of hospital communications failure or overload; Fax Machine; Photocopier; Internal telephones on a rotary basis; Site maps and white board; A rotated stock of torches, stationary and materials appropriate to the need; and, An AM/FM band radio. The Command Post will be established and maintained by the Occupational Health and Safety Unit. If an emergency requires response from the Queensland Police Service, Queensland Fire and Rescue Service or other professional response agencies, they will assume command once on site. They will liaise with the hospital Command Post for information and the use of hospital resources as required. Police may relocate the Command Post if necessary upon arrival. Alternative Command Post In the event that the primary Command Post can not be established, the alternate Command Post shall be located within: Boardroom Level 5 Woolworth s Building. Cancellation of Code After consultation with appropriate emergency services, members of the Command Group will determine and decide that a code is to be cancelled. This information will be registered with the Central Monitoring Room (Protective Services) who will initiate All Clear and advise of subsequent action. It is important to observe that All Clear is given followed by the emergency code corresponding to the emergency for which it relates. For example, if a fire led to a decision to evacuate, Code Red then Code Orange would be given. If the fire is extinguished prior to completion of evacuation then Code Red All Clear is given, followed by Code Orange All Clear. Version 1.0 June 2007 Page 11 of 53

Debrief At the conclusion of the activity a formal debrief and counseling sessions should be available for all staff. The Command Post Coordinator will be responsible to coordinate this in conjunction with the Debrief Services Coordinator. Occupational Health and Safety Requirements If, during the course of an Emergency, either of the following occur, Serious Bodily Injury: is an injury to a person that causes: Death The loss of a distinct part or an organ The injured person is absent from the person s voluntary or paid employment for more than 4 days Dangerous Event: one caused by workplace activity if it puts someone at risk because of: Collapse, failure or malfunction of - High risk plant - Building or other structure - Excavation or support of excavation Implosion, explosion or Fire Escape, spillage or leakage of hazardous substance or dangerous goods Fall from a height of plant, substance or object Damage to a boiler, pressure vessel or refrigeration plant Uncontrolled explosion, fire or escape of gas or steam The Manager - Occupational Health and Safety is to be immediately notified by pager through the switchboard. Version 1.0 June 2007 Page 12 of 53

SECTION 4: INTERNAL EMERGENCY (CODE YELLOW) 1. If necessary, move people to a safe area; 2. Dial 55, state CODE YELLOW, the location and the nature of the emergency; 3. Follow the instructions of the Senior Safety and Security Officer or authorized person in charge; 4. Prepare to evacuate if instructed by the Senior Safety and Security Office or authorized person in charge. Explanation Internal emergencies are any incidents that threaten the safety of the physical structure of the hospital, staff, patients and visitors. It may also reduce the capacity of the hospital to function normally. Such incidents include but are not limited to: Explosion; Natural Disaster (Earthquakes); Engineering failures (Burst water mains, loss of electrical power, gas leaks, air conditioning failures); Impacts on buildings or grounds; Incidents in the immediate surrounds of the hospital (Chemical spills, with noxious vapors affecting people); Illegal occupancy; Information and Communication failures. The internal emergencies that are most likely to occur in the hospital will be of short duration and low intensity. Staff in the affected area will manage such emergencies, with provision for coordination by the most senior staff member on site at the time of the incident. Some emergencies will escalate to a serious nature, and others will have a long time frame. In these situations, a Command Post, staffed by senior hospital personnel, will be established to manage the hospital activities and liaise with external Emergency Services. These incidents will require the systematic evacuation of patients and others from all or part of the hospital. CODE YELLOW To address these needs, this plan has specific modules for each incident category and for the systematic evacuation of the buildings. While any of these incidents prevail, the hospital is in an EMERGENCY CALL OUT. This affects deployment of personnel and command responsibilities. Principles of Emergency Response The basic principles of managing the response to an internal emergency are: Remove people from danger as quickly as possible Prevent other people inadvertently coming into a danger area Minimize the damage to the physical structure of the hospital Maintain role and re-establish services Version 1.0 June 2007 Page 13 of 53

GENERAL SERVICE FAILURE All General Service failures are to be reported to the switchboard by dialing 55 stating Code Yellow the nature and location of the failure. In addition to dialing 55, the following must occur: Water supply failure, electricity failure, ventilation contamination/failure the hospital engineering department is to be notified. During normal working hours contact the Manager Operational Services Ext 68309. For afterhours, notify the on-call Engineer and The Manager Occupational Health and Safety via the hospital Switchboard Gas Supply Failure. In the case of gas supply failure close off all gas outlets and contact the Manager Operational Services Ext 68309 during normal working hours. For after-hours, notify the on-call hospital Engineer and The Manager Occupational Health and Safety via the hospital Switchboard. Medical Gas Supply Failure. If the installed medical gas supply fails during normal working hours contact the Manager Operational Services Ext 68309. For after-hours, notify the on-call Bio-Medical Engineer and The Manager Occupational Health and Safety via the hospital Switchboard. Information and Communication Failure. During normal working hours contact the Manager Information and Technology Services Ext 61873. For after-hours, notify the on-call Information and Technology Officer via the hospital switchboard. * For patient life support, portable supplies may have to be used depending on the extent and nature of the supply failure. HAZARDOUS MATERIAL INCIDENT All hazardous material incidents are to be reported to the switchboard by dialing 55 stating Code Yellow the nature and location of the incident. The hazard category is to be displayed on the product container for ease of identification and to assist in determining the associated safety precautions. Additional information is to be provided via Material Safety Data Sheets (MSDS) which must be obtained from the distributor of the product. MSDS s are to be displayed in all areas which use or store products identified by the above classification system. Supporting signposting is also to be displayed where required. A current register of MSDS s is to be kept in all areas using hazardous substances. A central register is to be kept and maintained by the Occupational Health and Safety Unit. Emergency procedures will be based on the product classification and the information provided in the MSDS s. In all cases the emphasis must be on personnel safety and to confine the hazard to the immediate incident area. Emergency response decisions must also take into account potential environmental damage, e.g. avoid liquid spills entering the drainage systems. Localized call-out procedures are to be formulated for all areas using and/or storing hazardous substances to ensure availability of specialist knowledge in case of an accident and staff working in those areas are to be made aware of such procedures. Where necessary spill kits and clean up kits are to be made available for emergency response. CODE YELLOW STRUCTURAL DAMAGE All structural damage is to be reported to the switchboard by dialing 55 stating Code Yellow the nature and location of the structural damage. The following steps should be strictly adhered to when dealing with structural damage: 1. Attend to injuries and watch for hazards: Administer first aid. DO NOT move the seriously injured unless in danger. 2. Turn off utilities if applicable. 3. STAY CALM and help others if possible. 4. Evacuate ward/departments to safe areas. Record the people who are in or who have been evacuated from the building. If evacuated, record where to and time of evacuation. 5. Ensure media and unauthorized persons are kept from impeding operations Version 1.0 June 2007 Page 14 of 53

Staff Obligations Internal Emergency During the initial phase of an emergency, all staff will be under the direction of the Director, Safety and Security Services / Senior Safety and Security Officer or the senior staff member on duty in the affected area. In major incidents, a Command Post will be established who will assume responsibility for managing the event. The underlying principle of the plan is that as far as possible staff will be doing their routine job. While the EMERGENCY CALL OUT exists for the hospital, staff will be expected to undertake any allocated task for which they are physically capable position descriptions and duty statements are suspended during an emergency. Staff off-duty should not attend the site until the commencement of their normal shift and should not they telephone the site. This places a higher demand on the communication area. In situations where off-duty staff are called in to assist in making the hospital safe or evacuate patients, all staff are expected to return promptly to duty. It is the responsibility of managers / supervisors to ensure: Up to date call in list are maintained; and Switchboard Services is informed of changes as necessary. It is the responsibility of employees to: Be aware that their names are on the call in lists; Be aware of their obligations if called; Regularly exercise their roles in such emergencies; Know where to report to in evacuations. There is an obligation for all off duty staff to return to duty when requested in an emergency and assist as directed by the Command Post. Where staff do not have access to private transport, they may travel by taxi. The expenses incurred will be reimbursed if a receipt is obtained. Following the All Clear signal is given for a particular code, staff can return home (unless otherwise directed by the Manager). CODE YELLOW Version 1.0 June 2007 Page 15 of 53

Pedestrian Evacuation Traffic Operational Services will immediately put all lifts in the affected area under lift control, and move all lifts to the ground floor. Further use of the lifts will be dictated by the nature of the emergency and advice from the professional response personnel. Pedestrian Non-Evacuation Traffic Protective Services staff will ensure that all non essential personnel do not enter the hospital grounds. If the emergency is major, Police will assist in traffic control. Vehicular Traffic While the hospital is in Emergency Call out, only emergency response vehicles will gain access to the complex. Media Vehicles will not be permitted. Removal of Vehicles Vehicles that are legally or illegally parked could hinder emergency / rescue vehicles or teams. The Command Group may authorize the removal of any vehicle that is considered to be causing difficulties to emergency operations. Removal of vehicles is to be carried out by the Royal Automobile Club Queensland (RACQ). Cost of removing vehicles will be met by the district in the case of legally parked vehicles and by owners of those illegally parked. Vehicles are to be moved to a car park within the hospital grounds and away from the emergency scene. Illegal Occupancy The complex whether by virtue of drug stocks, medical records, valuables on the premises, or patients in Police custody, may become a target for illegal intruders. In the event of the above incident occurring, staff will: CODE YELLOW 1. Dial 55 to notify of the occurrence. In turn, the Senior Safety and Security Officer will: 1. Notify the Police and request assistance; 2. Ensure appropriate Emergency Services have been alerted; 3. Notify the Director, Safety and Security Services Department; 4. Initiate action to restrict: a) Entrance to the building / department (including clinical environment); b) Presence of illegal occupants to their entry point; and c) Contact between the illegal occupants and the building occupants. Version 1.0 June 2007 Page 16 of 53

EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Infection Control CNC Environmental Waste Coordinator Debrief Services Coordinator After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator CODE YELLOW Version 1.0 June 2007 Page 17 of 53

SECTION 5: EVACUATION (CODE ORANGE) The best option is to move laterally through smoke doors on the same level. Do not panic or shout as this may cause panic in others. An orderly response may save more people. Under no circumstances should lifts be used in a fire-related evacuation unless directed by the Queensland Fire and Rescue Service Officers. Under the direction of the Warden: Remove people from immediate danger area to a nearby safe area. Evacuate people in the following order: Ambulatory; Semi-Ambulatory; Non-Ambulatory. If possible, move personnel laterally to a safe area by passing through a fire door to an adjacent safe zone on the same floor. Move personnel vertically to the floor below (only upon instruction from the Area Warden, Security Officer or Queensland Fire and Rescue Service). Progressive Evacuation of the Building When evacuation requires movement outside the building, personnel will move via the defined route to the designated assembly area (usually via fire stairs). Evacuation charts within each compartment indicate the available egress routes. Depending upon the location of the emergency the appropriate route should be taken to enter the closest fire safe compartment. Explanation Evacuation involves the movement of patients, staff and other personnel within or from the health care facility in as rapid and safe a manner as possible. Training of employees in the principles of evacuation is of importance for an evacuation to be effective. CODE ORANGE Assessing the Situation A senior staff member present in the area at the time, before the decision to evacuate is made having regard to should assess the situation: Seriousness of the threat to human safety; Proximity of hazards which may be relevant to the situation; and The nature and type of patient in the area. Version 1.0 June 2007 Page 18 of 53

Authority to Evacuate The authority to order evacuation of the immediate area will rest with the Floor or Fire Warden or senior staff member present in that area at the time. Responsibility for the evacuation should be vested with the emergency controller who should act on his/her own initiative. The nurse in charge or medical officer (or both) should make designation of specific patients for immediate evacuation. Queensland Emergency Services will assume control on arrival. Stages in Evacuation Evacuation should be conducted in three distinct stages according to the severity of the emergency. 1. Removal of people from immediate danger 2. Removal to a safe area beyond fire or smoke doors 3. Complete evacuation of building Stage 1 Removal of people from the immediate danger area Patients and other personnel in the immediate area, and if necessary on that floor will, in the first instance, need to be assembled a safe distance from the cause. In the case of fire and smoke once the area has been evacuated, doors (other than automatic fire doors) should be closed to localize fire and smoke. Stage 2 Removal to a safe area Removal to a safe area. If the severity of the emergency warrants evacuation, movement should be through fire or smoke doors into an adjoining compartment. This may be horizontally or vertically to a lower level. Stage 3 Complete evacuation of a building Complete evacuation of a building. The nature of the incident may necessitate total evacuation of the building. Evacuation should be to an evacuation assembly point away from the affected building. Egress Routes The presence of fire or smoke (or both) in an emergency situation may govern the choice of evacuation routes and prohibit the use of nearby exits, in which case the nearest accessible exit should be used. Emergency officers play a vital role in education of staff and in controlling any necessary evacuations therefore prior knowledge of the building layout by staff is paramount. CODE ORANGE Lifts Lifts should not be used in a fire emergency unless authorized by the Queensland Fire and Rescue Service. Electric power may fail or be switched off causing people to be trapped. The lift shaft could act as a chimney and thus contribute to the spread of fire, heat, toxic fumes and smoke to other parts of the building. Fire isolate stairs, fire escapes and other safe routes should be used. Version 1.0 June 2007 Page 19 of 53

Evacuation of Personnel and Patients For the purpose of evacuation it is desirable to sub divide patients into three groups. Group 1 point. Group 2 Ambulatory patients requiring only a member of staff to guide or direct them to an evacuation assembly Semi-ambulatory patients requiring just a helping hand. Group 3 Non-ambulatory patients who have to be physically moved or carried. Mobility impaired persons that require some assistance. Assembly Areas In the event of a major fire/emergency, patients, visitors and staff will be advised of the required assembly area within the Royal Children s Hospital Complex by staff from Protective Services Department. Room Check / Record Collection When all people have been removed from the danger area, a staff member should check that the area is clear. Provided no risk is involved, staff lists and patients records should be collected. NOTE: Do not enter smoked filled areas without suitable breathing apparatus. Fire Exit Monitors A staff member should be positioned to prevent other persons inadvertently entering the danger area by alternative entrances provided no risk is involved and the person nominated can be spared. A head count should also be conducted once the evacuation is complete. Staff and patients must be advised to stay in the evacuation area to enable an accurate head count to be made. The senior staff member or delegate should report to the Queensland Fire and Rescue Service Officer or Security Officer represent to advise if anyone is missing. CODE ORANGE Factors for Consideration Factors that must be considered in the emergency handling of patients include: The nature of the emergency; The weight and condition of the patient; The strength, skill and training of the rescuer(s); The height of the bed; and The availability of resources, both human and material (this includes evacuation sheets). Correct listing techniques should be observed at all times. The beds of intensive care patients may be wheeled to safety if the situation permits. Do not obstruct corridors, doorways and stair entrances with beds or bedding. Version 1.0 June 2007 Page 20 of 53

Ambulatory Patients Ambulatory patients should be gathered into a group and escorted to a safe area. A competent person must assume control to minimize panic and ensure that all are accounted for. Ambulatory patients and visitors may be usefully employed in the orderly removal of other ambulatory patients. Wheelchair Patients If the need for wheelchairs is acute, patients who have reached a safe area should yield their chairs so that other patients may be evacuated. Non-Ambulatory Patients Non-Ambulatory patients may be carried on stretcher, blankets or specifically designed equipment, e.g. evacuation sheets and emergency backboards. They may also be moved by emergency removal techniques such as: Blanket drag and team lifting. Patient Care Following Evacuation After patients and staff are evacuated, the All Clear may be given. Patient care will probably require an extraordinary effort by staff until such time as the patients can be retuned to their ward, found alternative accommodation within the health care facility, or transported to another health care facility. General Wherever practical, parents and their children should be kept together during evacuation. Where parents and children are separated, they should be reunited at the earliest stage after evacuating. This will prevent parents attempting to search for their children. Parents/visitors should be involved in the evacuation process wherever necessary to ensure patient safety and in particular where their own children are involved. CODE ORANGE The use of bassinettes, cots, beds and trolleys must not be allowed to present additional hazards by obstructing exit routes unnecessarily. The number of cots and beds used for instance can be minimized by placing more than one patient in each cot for evacuation purposes. During evacuation it is important, wherever possible, to ensure the area to be evacuated is thoroughly searched to confirm everybody is out. This is the only effective way of ensuring a complete evacuation. If there is an area that cannot be effectively searched, this should be immediately reported to Protective Services or Emergency Services on their arrival. The concept of staged evacuation makes it very difficult to identify specific assembly points. Circumstances surrounding the incident may also exclude a previously identified assembly area. The main aim is to remove people from immediate danger to an area of relative safety. Supervisors/Line Mangers generally, should consider a number of options as part of their emergency response pre-planning, and discuss options with their staff. Version 1.0 June 2007 Page 21 of 53

SISTER WARDS An evacuation of patients being placed outside of a building will in addition to subjecting the patient to the weather conditions at the time, effectively reduce the availability of: Medical Air and gas Suction Communication Medical Support A Sister Ward is a safe area for patients, in another fire compartment. Sister Ward protocols should be developed with at least two other wards/departments with similar medical functions. This process would be reciprocal and should be confirmed on a monthly basis. CODE ORANGE Version 1.0 June 2007 Page 22 of 53

EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Infection Control CNC Environmental Waste Coordinator Debrief Services Coordinator After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator CODE ORANGE Version 1.0 June 2007 Page 23 of 53

SECTION 6: FIRE (CODE RED) Explanation The procedures and equipment discussed below relate to the initial response to a fire emergency, and not for any long term action. Standard procedures will normally have a safety and security officer at the site of the fire alarm in less than two minutes. The Queensland Fire and Rescue Service can be expected on site within five to seven minutes. The campus is equipped with a comprehensive range of thermal and smoke sensors, incorporated into alarm systems directly connected to the Queensland Fire and Rescue Service. In addition, fire hoses and portable fire extinguishers are available to provide the initial response to an emergency, as well as automatic fire doors and pressurized stairwells to contain smoke in the affected area to allow safe egress from the danger area. Fire alarm system sounds like: Notifying of a possible danger. BEEP - BEEP - BEEP - BEEP and CONTINUOUS RING OF THE FIRE BELLS WHOOP, WHOOP, WHOOP EVACUATE AS DIRECTED or UNLESS YOU ARE IN IMMEDIATE DANGER Reporting a Fire Phone 55; On hearing this alarm, you should check your immediate area for any dangers. Do not evacuate unless a possible danger exists. Follow direction of your Wardens and Emergency Services personnel. On hearing this alarm, you should prepare to evacuate to an assembly point or sister ward if required All staff are to follow the instruction from their Wardens and Emergency Services personnel. CODE RED Advise your name and classification e.g. Registered Nurse; Location of the fire, what is burning, if patients are been activated; Do not shout or panic, this may cause confusion; Where possible isolate any oxygen by closing the shut-off valve; Remove oxygen bottles from the area. Version 1.0 June 2007 Page 24 of 53

Action in the event of a Fire Alarm Activation Fire alarm activation is the signal for all staff members to promptly and thoroughly check the immediate location for signs of smoke or flame. If, during the routine search, smoke or flame is located, proceed immediately into the Code Red procedure. If above ground level, make contact with the department situated on the floor below to ascertain whether a problem exists. The presence of a fire will require the activation of Code Orange. In the event that there are no signs of fire or smoke, advise the fire warden in the area and await further instruction or the All Clear. Under no circumstances should staff contact the Central Monitoring Room to advise that a fire alarm is activating. The Emergency Operator will be aware of the alarm and Safety and Security personnel will be responding. Making calls of this nature will cause unwanted congestion of the emergency lines and may result in delaying assistance to an area involved in a fire emergency. Action on discovery of a Fire For immediate action remember the acronym R.A.C.E. a) REMOVE patients from immediate danger. Do not obstruct exits and exit routes. Those patients in the danger area who are dependent upon electrically operated equipment or are non-ambulant must receive special attention. b) ALERT staff in close proximity of the danger, staff should activate a MANUAL CALL POINT ALARM (break glass/press button) and Dial 55 and inform the Switchboard Operator. (Code RED) c) CONFINE fire and smoke by closing doors and, where practical, windows. This action will localize fire and smoke and reduce spread. d) EXTINGUISH or contain the fire, DO NOT TAKE UNNECESSARY RISKS. Operate portable fire extinguisher or hose reels to extinguish or contain the fire. Only if it is safe to do so and you have been trained in their use. Actions such as removal of patients from the place of danger, informing Switchboard Services and the operation of appropriate fire fighting equipment are actions which, depending on the availability of staff, should as far as practical, be undertaken simultaneously. Lifts should not be used in a fire emergency unless directed by Queensland Fire and Rescue Service Officer. Fire Fighting Equipment All staff should know the location and use of fire fighting equipment in their area. All areas of the hospital have fire hoses and portable extinguishers. The location of the fire fighting equipment is indicated on the evacuation plan displayed in each area. CODE RED Use of inappropriate extinguishers can make the situation worse. Water based equipment used on fires involving energized electrical equipment can result in electrocution. Furthermore, water from a hose or extinguisher applied to burning flammable liquids will spread the fire. Fire Extinguishers Fire extinguishers are mounted on brackets either on the wall or in fire hose cupboards depending upon the hospital location. Make certain that you are familiar with the action required. Know how to activate the fire extinguishers in your area. Free the extinguisher from the bracket. Manage the weight of the extinguisher. Break the seal. Release the safety pin. Squeeze the trigger or lever. Hold and direct a hose if necessary Version 1.0 June 2007 Page 25 of 53

Carbon Dioxide Red with black band around the body. Most appropriate for fires involving energized electrical equipment. Dry Chemical Powder Red with a white horizontal band around the centre of the cylinder. Use for flammable liquids or ordinary combustible fires. Safe for use when energized electrical equipment is involved. Leaves a very large residual powder. Water Extinguishers Red. Use for paper or wood fires. Foam Extinguishers Blue. Use for flammable liquid fires. Fire Hoses Located throughout the buildings are hose reels, which are effectively large garden hoses. Do not use Fire Hoses if: Live electrical circuits are in area of the fire. CODE RED Flammable liquids are the source of the fire. Turn on the hose at the valve attached directly to the hose reel (in some cases this also releases the hose from a clamp). The hose is still turned off at the nozzle. Drag the hose to the scene of the fire. Turn the nozzle in the direction as indicated on the nozzle. Play the stream of water on the fire. If hose nozzles are fitted with an upright lever pull or push the lever to activate the hose. Fire Blankets The fire blanket is a smothering device only. It is a SINGLE USE ITEM. Once used, fire blankets must be discarded and replaced with a new one. Fire blankets are not safe to use where an energized electrical field is present. Version 1.0 June 2007 Page 26 of 53

EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Infection Control CNC Environmental Waste Coordinator Debrief Services Coordinator After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator CODE RED Version 1.0 June 2007 Page 27 of 53

SECTION 7: BOMB / ARSON THREAT (CODE PURPLE) INTRODUCTION The bomb threat is a situation requiring considerable assessment prior to any response decisions being made. There are likely to be numerous variables involved, all contributing to the difficult decision making process. The basic nature of a hospital provides ready access to a potential bomber and it would be very easy for somebody to plant a device undetected. A bomb is easily disguised in many ways, but the last thing it will look like is a bomb. The following guidelines are provided to assist with threat assessment and the subsequent response action. To minimize any possibility of panic, staff are to ensure in the initial stages that patients and visitors are not made aware of any threat. Staff must keep calm and act in as normal a manner as possible. THREAT -TYPES Threats may be in one of the following forms: Written Threat: If a bomb threat is received in writing, the document should be kept, including any envelope or container. Once a message is recognized as a bomb threat, further unnecessary handling should be avoided. Every possible effort has to be made to retain evidence such as possible fingerprints, handwriting, paper and postmarks. Telephone Threat: An accurate analysis of the telephone threat can provide valuable information on which to base recommendations, action and subsequent investigation. The person receiving the bomb threat by telephone should not disconnect the call and, as soon as possible, should complete the information required on a Bomb Threat checklist. This checklist should be completed in conjunction with the received threat call. Suspect Object: A suspect object is any object found on the premises and deemed a possible threat by virtue of its characteristics, location and circumstances. CODE PURPLE Version 1.0 June 2007 Page 28 of 53

Bomb Threat Receipt Checklist QUESTIONS TO ASK When is bomb going to explode? Where did you put the bomb? When did you put it there? What does the bomb look like? What kind of bomb is it? What will make the bomb explode? Is there more than one bomb? Did you place the bomb? Why did you place the bomb? What is your name? Where are you? What is your address? EXACT WORDING OF THREAT ACTION Report call immediately to: Switchboard Phone extension: 55 CALLER S VOICE Accent (Specify) Any impediment (Specify) Voice (e.g.: loud, soft) Speech (e.g.: fast, slow) Diction (e.g.: clear, muffled) Did you recognize the voice? If so who do you think it was? Was the caller familiar with the area? THREAT LANGUAGE Well spoken: Incoherent: Irrational: Taped: Message read by caller: Abusive Other: BACKGROUND NOISES Street noises House noise: Aircraft: Voices: Music: Machinery: Other: Sex of caller: Estimated age: Long Distance: STD: CODE PURPLE CALL TAKEN Date: Number called: Duration of call: Time: RECIPIENT Name (print): Telephone Number: Signature: Version 1.0 June 2007 Page 29 of 53

Bomb / Arson Threat Search Checklist This form should be completed following receipt of a Code Purple threat. The form should be completed by the senior person on shift and forwarded immediately to the Emergency Controller. Time: Date: Location: All staff members in the work area advised Following area searched: Toilets / Showers Work area / ward / room Corridors Cupboards Storage Lockers Linen trolleys Office areas / Work stations Exits Time Completed: Suspicious item located CODE PURPLE If Yes mark location on copy of map in your area and forward it immediately to the Command Group. Person completing report: Signature: Date: Version 1.0 June 2007 Page 30 of 53

ROLES AND RESPONSIBILITIES The very nature of a bomb threat means that there is likely to be a wide and varied staff response. The following nominated staff responsibilities are related to the initial response and should not detract from the roles and responsibilities of other specialist, and supervisory staff, who may become involved during an incident. Those roles and responsibilities will be consistent with positions held in the hospital, e.g. District Manager, Executive Members, Manager Operational Services and The Manager Occupational Health and Safety. General Responsibilities In the event of a bomb threat, remain calm and always treat the threat as genuine. If the threat is received by telephone:- 1. Prolong the conversation for as long as possible as an open phone line can be traced. Do not hang up- even if the caller does. 2. Ask another person to Dial 55 and report the type of emergency, the location and any other information. 3. Immediately complete the bomb threat checklist 4. Notify your Line Manager/Floor Warden on duty, who will take the following action:- Ensure that the Switchboard Services has been contacted. (55) Instruct personnel to look for any suspicious/out of place objects but not to touch any objects found and organize a visual search of the area. Clear all patients, visitors and staff from immediate area. Report any finding to Switchboard Services, Dial 55 immediately. Stand by for further instructions. Do not prepare for evacuation until further advice is received. Once the decision has been made to evacuate the area, patients, staff and visitors should be evacuated to the nearest evacuation assembly point, unless otherwise advised. Search Those best qualified to conduct a thorough search in any given area are the occupants. These persons have knowledge and a better understanding of what belongs or what does not belong in a location at any given time. Police will not possess an intimate knowledge of the threatened area and, although prepared to assist, would be less likely to recognize what could be suspect. CODE PURPLE The aim of the search is to identify any objects that are not normally found in an area or location, or for which an owner is not readily identifiable or becomes suspect for any other reason e.g. suspiciously labeled - unusual size, shape and sound -presence of pieces of tape, wire, string or explosive wrappings. The search should begin in public areas such as foyers, lobbies, corridors, stairwells, toilets and waiting rooms, and then extend to all other areas. The search should be thorough, eliminating those areas that are locked and unavailable to the public If the caller indicates the area in which the bomb is located, this area should receive immediate attention. Tight security should be maintained on each area searched until the entire search is completed. If what appears to be a bomb is found Do Not Touch It. Clear the area and obtain professional assistance. Doors and windows should be left open to reduce the blast effect of any explosion. Search of other areas should continue to ensure that there are no other suspect objects. NOTE: NO HAND HELD RADIOS TO BE USED IN THIS SITUATION DUE TO RADIO FREQUENCY IMPLICATIONS Version 1.0 June 2007 Page 31 of 53

Evacuation Following an analysis of information received, the emergency controller will make the decision whether to institute one of three possible actions, as follows: 1. Search without evacuation 2. Evacuate and search 3. Evacuate (without search) Search without Evacuation If the decision is made to search without evacuation, the Emergency Controller will execute the following: Alert all Emergency Officers and Police of the situation, specifying the location if known. If the location is unknown, state it is unknown. Delegate Emergency Officers to supervise and assist in the search for any objects. All members of staff shall search their immediate areas. A sticker should be placed on each section of an area after a search has been completed to indicate that each area has been searched. If any suspect object is found, the senior staff member will notify the Emergency Controller IMMEDIATELY. The Emergency Controller will ensure that it is not touched or moved and that the area is kept clear. The Emergency Controller will notify the Police and Switchboard Services Operator IMMEDIATELY that a suspect object has been located. The operator will notify the following officers: District Manager Executive Director Corporate Services Manager Operational Services Manager Occupational Health and Safety Evacuation and Search CODE PURPLE Prior to an evacuation being commenced all egress routes to and including assembly areas MUST be searched and declared free of secondary explosive devices. All doors must be left open to allow release of energy should an explosion occur. Implement ANNOUNCEMENT OF CODE ORANGE: As soon as all persons are at the evacuation assembly point, all persons will move to a secondary assembly area at least 100 metre distance from the building where the bomb is placed. Partial Evacuation Version 1.0 June 2007 Page 32 of 53

One alternative to total evacuation is a partial evacuation. This response is particularly effective when the threat includes the specific or general location of the placed object or in those instances where a suspicious object has been located without prior warning. Partial evacuation can reduce risk of injury by evacuating ambulatory patients, visitors and non-essential personnel. Staff essential to a search can remain, critical services can be continued and in cases of repeated threat, risk of injury is minimized. Safety Factors Immediate and total evacuation would seem to be the most appropriate response to any bomb threat. However, there are significant safety factors associated with a bomb threat that may weigh against an immediate evacuation. These are as follows: Risk of injury: As a general rule, the easiest area in which to plant an object is in the shrubbery sometimes found outside a building, an adjoining car park or in an area to which the public has the easiest access. Immediate evacuation through these areas may increase the risk of injury. Car parks should not normally by used as assembly areas. The Emergency Controller will ensure that egress routes and assembly areas are searched for suspicious objects, prior to any evacuation. Response impairment: total evacuation will remove personnel who may be required to make a search. Panic: A sudden bomb threat evacuation may cause panic and unpredictable behavior, leading to unnecessary risk of injury. Patient dependency: At least some of the patients in any area under bomb threat may be dependant on life support equipment. Reduction in-patient care: Although the evacuation of patients to any assembly area may ensure their safety, repeated threats and evacuations could compromise patient care. Search after Evacuation If the decision is made to evacuate (without search), the Emergency Controller will try to see that personal belongings are removed. Experts will check unidentified and unattended suspicious objects (no attempt to remove such objects will be made). The following areas including will be search in the order stated below: 1. Outside areas including evacuation assembly areas. 2. Building entrances and exits, and in particular evacuation routes. Public areas within buildings. 3. Other areas. After external and public areas have been cleared, a search should be conducted beginning at the lowest levels and continuing upwards until every floor, including the roof, has been searched. After a floor or room has been searched, it should be distinctively marked to avoid duplication of effort. Version 1.0 June 2007 Page 33 of 53

EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Infection Control CNC Manager - Environmental Waste Coordinator Debrief Services Coordinator After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator CODE PURPLE Version 1.0 June 2007 Page 34 of 53

SECTION 8: PERSONAL THREAT (CODE BLACK) Armed or Unarmed Persons Threatening Injury to others or themselves This procedure is the initial response to personal threat that may arise from an armed or unarmed person confronting staff or others in a violent or threatening manner or where a person threatens to commit suicide. Once Protective Services, Police or other professional response groups arrive, they will assume command. Under no circumstances should staff, patients or visitors place themselves in further danger. No amount of money or property is worth risking a life. Wherever there are unlawful demands for hospital property (money, drugs, equipment) with threats of violence, the property should be handed over without question. Armed Confrontation In a situation of armed confrontation, hostage taking or siege, it is most important that staff, patients or visitors do not place themselves at further risk. Staff should undertake the following procedures: a) Obey the offender s instructions, but do only what is told and nothing more, and do not volunteer any information. b) Stay out of danger if not directly involved, leaving the building if it is safe to do so. Raise the alarm - Dial 55 c) Activate an emergency duress alarm if installed or phone the emergency number - Dial 55 (if able to do so without danger). d) Carefully observe any vehicle used by the offender(s), taking particular note of its registration number, type and colour, number of occupants and their description. e) Observe the offender(s) as much as possible. In particular, note the speech, mannerisms, clothing, scars or any other distinguishing features and record these observations in writing as quickly as possible after the incident, make as many notes as possible. A descriptive form is contained in Appendix 9.5. This information should be given Protective Services or Police on their arrival. f) Close off area when offender(s) has left. Do not allow anybody in these areas until the police have authorized access. CODE BLACK g) All witnesses should be asked to remain until the Police arrive. Explain to witnesses that their view of what happened however fleeting, could provide vital information when pieced together with other evidence. Drug Hold Ups The Pharmacies and every clinical area are potential sites for unlawful demands for drugs. Where possible you should tell the offender that the demanded drugs are not held in the area or that the key to the storage cupboard is unavailable. If the threats become more menacing, then every effort should be made to meet the offender's demands. If there are genuine inhibitions to meeting demands, such as not having the key to drug cupboards, and then explain the procedure used to access the drugs, and why you are unable to access them. For any type of hold up, try to keep a mental note of the goods taken, and as soon as the threat is removed, write down the list of stolen property. It is also important that nothing is touched and only essential people enter the area until the Police are on site, so that fingerprints and other evidence are maintained intact. Version 1.0 June 2007 Page 35 of 53

Threatening and Nuisance telephone Calls Threatening Phone Calls: are defined as telephone calls that cause genuine concerns for the safety of staff and/or patients. The Police can formally deal with these calls. Nuisance Phone Calls: are defined as Non life threatening. The work unit supervisor will report to these calls. The police will decide what, if any action will be taken. Action: Do not hang up the phone as this call may be traced (for handsets that display the number, record it BUT DO NOT HANG UP). Pass all information received immediately to your supervisor and inform Switchboard Services of the Personal Threat by dialing 55. Record all information on the Personal Threat card located in this plan or at the front of the internal Telephone Directory. Armed Hold Up Armed hold up is the most likely personal threat. This could be for cash, drugs or some other item. In all cases, the persons in contact with the offender should be as compliant as possible, while carefully trying to signal to other staff to raise the alarm. Cash Hold Up The numbers of locations in the hospital with large amounts of cash are few, and those areas are generally designed to provide reasonable physical security. If demands are made for money, the cash should be handed over in a deliberate manner. Always attempt to give coins and low denominations first as this will delay the offender and increase the chances of apprehension. This practice should stop if the offender becomes agitated and more threatening. Where duress alarms are installed, the alarm should be activated, taking care not to indicate to the offender that the button is being pressed. These alarms are silent and register at the central Monitoring Room where, the Senior Safety and Security Officer will be advised. Hostage The hostage may be a patient, staff member or a visitor. The reasons for taking such a hostage are almost infinite, but could include: demands for money or drugs; demands for action or inaction regarding treatment of an individual (this may or may not be the offender); some political motive, retribution for some real or perceived wrong, or a domestic upheaval. CODE BLACK The major concern should be to minimize the number of hostages and to minimize the risk to others. People, who can, should immediately vacate the area of threat. The offender s instructions should be carried out as precisely as possible. A Command Post would be established to manage liaison between the Police, Hospital personnel and the threat area. The location will depend upon the site of the threat, and all communication could be relayed through the Switchboard Services Operator. It is important that there is a clear understanding of the nature of the demands including the reasons for the event and the expectations of the offender. The Emergency Controller or Senior Safety and Security Officer must relay this information to the Command Post. Version 1.0 June 2007 Page 36 of 53

Irrational Person When an irrational person undertakes a campaign of damage against personnel and / or the fabric of the hospital, this is essentially an unmanageable situation. The first concern should be to move as many people away from the expected path of the offender. If these people cannot escape from the vicinity, they should minimize their exposure by moving behind furniture (for example) that will isolate them from the offender. Phoning 55 will raise the alarm; the Operator will contact Protective Services and the Police. All personnel, who can, should vacate the threatened areas as quickly as possible. If possible personnel should exit singularly, not in groups to minimize target opportunities. CODE BLACK Version 1.0 June 2007 Page 37 of 53

Personal Threat Receipt Checklist PERSONAL THREAT RECEIPT CHECKLIST REMEMBER KEEP CALM PERSONAL DESCRIPTION FORM OF OFFENDER (For use to record relevant description of the offender) NAMES OR NICKMANE USED: APPROXIMATE AGE: HEIGHT: NOTES FOR COMPILATION Separate form required for each person. To be compiled immediately after the incidents by each staff member, also bystanders if possible. Please tick as applicable. If answer is unknown write UK against heading. Do not consult others during compilation. Senior officer to collect forms and hand to the police. COMPLEXION: fair dark pale SEX: Male Female Pimply fresh ruddy sun-tanned ETHNIC ORIGIN: WEIGHT: ACCENT: BUILD: thin stout medium nuggetty VOICE: clear loud thick slangy POSTURE: erect stooped slouchy SPECTACLES: Colour: Shape: WALK: quick springy slow limp pigeon-toe HAIR: Colour: MOUSTACHE BEARD: Type: DISGUISE: Straight wavy bald curly thick long crewcut EYES: Colour: Size HANDS: Size: Intense stare squin Callused soft hairy EARS: Size: Shape: NOSE: Size: Shape: LIPS: Size: Shape: TEETH: good uneven spaced missing bad Nails missing or deformed fingers GLOVES: Type: Colour: JEWELLERY: SCARS OR MARKS: METHOD OF OPERATION: What did the CLOTHING: Including hat, tie, shirt, coat, trousers, offender do, say, touch, carry, etc dress, skirt, jumper and shoes: CODE BLACK SIGNATURE: NAME OF PERSON FILLING OUT THIS FORM: ADDRESS: WEAPON TYPE: METHOD AND DIRECTION OF ESCAPE: Make of Car : Model: Colour: Number of vehicles: Version 1.0 June 2007 Page 38 of 53

EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Infection Control CNC Environmental Waste Coordinator Debrief Services Coordinator After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator CODE BLACK Version 1.0 June 2007 Page 39 of 53

SECTION 9: ROLE DESCRIPTION TABLE EMERGENCY CALL OUT LIST Switchboard Services Operators will be pivotal in assisting with the appropriate response. Operators will only be required to contact the key personnel on the Call in list. A cascade system will be used for staff where the primary contacts call in other personnel as required. Periodic updates will be provided on progress with the calling in of staff, to Command Post Command Group will provide instructions for dealing with inquiries from: Emergency response services; The name of the hospital staff member responsible for media inquires. Remember communication capacity will be severely taxed during an emergency, so restrict calls to critical matters do not phone for an update. Normal Working Hours (Mon to Fri) Protective Services District Manager District Director Nursing Services Executive Director Corporate Services Executive Director Medical Services Manager Operational Services Manager Information & Technology Services Manager Occupational Health and Safety After Hours, Weekends and Public Holidays Protective Services After Hours Nurse Unit Manager (On Duty) Nursing Director (On Call) Executive Director Corporate Services Executive Director Medical Services (On Call) Engineering Services (On Call) Manager Information & Technology Services Occupational Health and Safety Officer (On Call) Divisional Director (Affected Area) Specialist Support Staff: Radiation Safety Officer Biomedical Technology Services Engineering Services Specialist Support Staff (On Call): Radiation Safety Officer Biomedical Technology Services Environmental Waste Coordinator Infection Control CNC Environmental Waste Coordinator Debrief Services Coordinator Version 1.0 June 2007 Page 40 of 53

COMMAND GROUP ROLE DESIGNATED OFFICER ALTERNATE INITIAL LOCATION OFFICER Command Post Coordinator Executive Director of Corporate Services Manager - Operational Services Level 5 Woolworths Building Command Post Officer Executive Support Officer OH&S Support Officer Level 5 Woolworths Building Nursing Activities Coordinator Executive Director of Nursing Nursing Director for specific area Level 5 Woolworths Building Operational Support Services Coordinator Manager - Operational Services Assistant Manager - Operational Services Level 1 Coles Building Inpatient Movement Coordinator Executive Director of Medical Services Deputy Director of Medical Services Level 5 Woolworths Building Security Services Coordinator Manager Security Services RBWH Senior Safety and Security Officer RBWH Building 15 RBWH Media & Public Affairs Coordinator Manager Public Affairs Public Affairs Officer Ground Floor North Tower Occupational Health & Safety Coordinator Manager OH&S District Occupational Health & Safety Officer 1 st Floor North Tower Building Coordinator Asset Manager Buildings & Plant Director Engineering & Building Services RBWH Ground Floor North Tower Information Technology Coordinator Manager Information & Technology Services Principal District Electronic Publisher 1 st Floor North Tower Support Call out Staff ROLE DESIGNATED OFFICER ALTERNATE INITIAL LOCATION OFFICER Radiation Safety Coordinator Radiation Safety Officer Radiation Safety Officer Block 8, C Floor RBWH Biomedical Technology Coordinator Biomedical Technology Officer Biomedical Technology Officer Block 8, C Floor RBWH Environmental Waste Coordinator Manager, Environmental Waste Environmental Waste Officer Engineering Services RBWH Debrief Services Coordinator CNC Rehabilitation & Manual Handling Manager Occupational Health and Safety Level 1 Woolworth s Building Infection Control Coordinator Director of Infectious Diseases CNC Infection Control Level 4 Woolworth s Building Version 1.0 June 2007 Page 41 of 53

EMERGENCY CONTACT TELEPHONE NUMBERS Medical Emergency Number (Code Blue) 444 Internal Emergency Number 55 Ambulance 131 233 Queensland Fire and Rescue Service 3247 5538 Queensland Police Service 3364 6464 State Emergency Service 3403 8888 Energex 136 262 Boral Gas Energy 1800 808 526 Bureau of Meteorology 1300 659 219 Hospital Switchboard 9 Contact Position Extension Number Pager Number Mobile Number District Manager 68262 N/A Switchboard Services Executive Director of Medical Services 68261 58759 Switchboard Services Deputy Director Medical Services 63788 59498 Switchboard Services Executive Director Nursing Services 67577 59589 Switchboard Services Executive Director Corporate Services 67353 N/A Switchboard Services Executive Director Allied Health 67439 59094 Switchboard Services Director Infectious Diseases 68654 29354 Switchboard Services Nursing Director Surgical Services 67277 59133 Switchboard Services Nursing Director Medical Division 63767 59314 Switchboard Services Executive Support Officer 67591 N/A Switchboard Services Nurse Manager Clinical Equipment and 61485 58929 Switchboard Services Consumables Nurse Manager TASU 63447 42156 Switchboard Services After Hours Nurse Manager 68265 42156 Switchboard Services Media & Public Affairs 61683 N/A 0412 361 752 Manager - Occupational Health and Safety 68164 58849 0413 309 684 District Occupational Health & Safety 65182 N/A 0403 449 192 Officer Asset Manager Building and Plant 67610 59506 0402 268 069 CNC Rehabilitation and Manual Handling 63628 41465 Switchboard Services CNC Infection Control 67856 48241 Switchboard Services Occupational Health Unit 67626 41438 N/A Manager Operational Services 68309 N/A 0402 415 617 Assistant Manager Operational Services 68445 41026 Switchboard Services Operational Services Shift Supervisor 68308 42069 0402 268 065 (0630 2230) After Hours Wards persons (2230 0630) N/A 42195, 42186, 42045 N/A DEM RCH 67900 N/A N/A DEM RBWH 67109 N/A N/A Protective Services 65188 N/A N/A Engineering and Building Services 61670 N/A N/A (General) Engineering Fitter on Call 68363 42701 Switchboard Services Engineering Electrician on Call 67179 58608 Switchboard Services Manager Information & Technology 61873 26105 0432 462 451 Services Principal District Electronic Publisher 69586 N/A Switchboard Services Manager Security Services RBWH 67945 59544 0407 114 672 Radiation Safety Officer 67211 59448 0414 549 239 Manager Environmental Waste 61424 N/A 0421 614 852 Biomedical Engineering 65688 57682 N/A Version 1.0 June 2007 Page 42 of 53

COMMAND POST COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Executive Director Corporate Services Manager Operational Services DEM Resources Work Room Duties The purpose of this position is to evaluate the emergency from the information provided, to decide the level of assistance that will be required from key support services (Security, Operational Services, Engineering and Building Services) and to coordinate effective delivery of this support. Oversee the establishment of the Command Post in the DEM Conference Room. Check telephones including dedicated outside line, stationary, torches and materials. Liaise with all command group personnel regarding updated internal emergency logistics and potential implications for services. Liaise with command coordinators and support staff to ensure the following: Effective communication systems are maintained Stores (non-pharmaceutical, linen are available and delivered to necessary areas Traffic control within the RCH complex is coordinated in an effective manner Engineering and Building Services staff are available to assist if required COMMAND POST OFFICER Version 1.0 June 2007 Page 43 of 53

DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Executive Support Officer Occupational Health and Safety Support Officer DEM Resources Work Room Duties The purpose of this position is to provide administrative support to the Command Group. Undertake the task of contacting support call out staff to provide extra assistance to the Command Group. Coordinate subsequent meetings and liaison between members of the Command Group. Provide assistance to formulate correspondence internally and externally as required. NURSING ACTIVITIES COORDINATOR Version 1.0 June 2007 Page 44 of 53

DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Executive Director of Nursing Nursing Director (Specific Area) DEM Resources Work Room Duties The purpose of this position is to evaluate the nursing requirements of the Emergency from the information provided and to brief relevant nursing staff of anticipated requirements. Contact all nursing Directors, Nurse Unit Managers relevant to the Internal Emergency. Arrange for the Bed Manager to work with the Command Post Coordinator including the District Manager to establish available beds in the event that a ward is relocated due to the Internal Emergency. Assign a Nursing Director to liaise with individual Nurse Unit Managers to recruit extra staff as required. Make decisions regarding all aspects of the nursing response, utilizing Nursing Directors and Nurse Unit Managers to carry out these requests. Assess ongoing staffing required to service key hospital areas, whilst maintaining an adequate service for pre-existing patients. OPERATIONAL SUPPORT SERVICES COORDINATOR DESIGNATED PERSON: Manager Operational Services Version 1.0 June 2007 Page 45 of 53

ALTERNATE PERSON: LOCATION: Assistant Manager Operational Services DEM Resources Work Room Duties The purpose of this position is to coordinate Porterage, cleaning of specific areas, and provision of food / refreshments during the emergency. Liaise with Command Post Coordinator to determine needs and operational staffing. Allocate staff to coordinate routine cleaning of primary areas not involved directly in the Internal Emergency. Allocate extra staff to clean the affected area/s. Audit existing supplies of consumables (tea, coffee, milk and sugar) and likely requirements during the Internal Emergency and obtain further consumables if required. Provide consumable (tea, coffee, milk and sugar) to areas on a needs basis. Facilitate catering supplies for the affected areas at the request of the Command Post Coordinator. INPATIENT MOVEMENT COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: Executive Director Medical Services Deputy Executive Director Medical Services Version 1.0 June 2007 Page 46 of 53

LOCATION: DEM Resources Work Room Duties The purpose of this position is to ensure the availability of beds for patients who may be transferred from an affected ward and to cancel elective admissions where necessary. Maintain the status of bed availability throughout the hospital. Liaise with Command Post Coordinator regarding internal emergency logistics and potential implications for services. Facilitate the discharge of appropriate patients in conjunction with relevant clinicians / wards. SECURITY SERVICES COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: Manger Security Services (RBWH) Senior Safety and Security Officer (RBWH) Version 1.0 June 2007 Page 47 of 53

LOCATION: DEM Resources Work Room Duties The purpose of this position is to provide security services assistance to the Royal Children s Hospital throughout the response to an Internal Emergency. Alert staff of Protective Services to the Internal Emergency, and call in additional staff as required. Deploy officers to traffic control points at Herston Rd, Bramston Terrace and Bowen Bridge Rd to prevent access of unauthorized vehicles. Ensure the Media does not block access points (main entrance or DEM) and direct Media to the Media assembly area located in the Auditorium - Education Centre, Level 5 Woolworths Medical Building or the Foyer RCH Foundation Building depending on the location of the Internal Emergency. MEDIA AND PUBLIC AFFAIRS COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Manager Public Affairs Public Affairs Officer Ground Floor North Tower Version 1.0 June 2007 Page 48 of 53

Duties The purpose of the position is to handle media requests, coordinate a media response, and to arrange media relations logistics including press conferences, media releases and statements. Set up the media assembly area with fax and computer facilities, diverting all phones from the offices of Public Affairs and the District Manager to the media assembly area. Advise the switchboard to direct all media requests to the media assembly area (advise specific extension numbers). Liaise with the Command Post Coordinator on the status of the Internal Emergency. Facilitate time schedule for a press conference (if required) and state exact location, time and identity of spokesperson. Draft Top Drawer media statement for standby broadcast on fax-stream to media outlets statement to the brief and factual, acknowledging occurrence or an announcement of the details at the scheduled press conference. Issue summary Media Statement to outlets that made direct contact. Alert the Queensland Health Public Affairs Director of the emergency situation. Alert the Ministerial Media Policy Advisor of the emergency situation. Alert all RCH staff of the emergency situation. Alert the RCH Foundation of the emergency situation. Ensure a meeting room is set up (40 chairs theatre style) to host a media press conference at any stage throughout the emergency. Set up a media assembly area for interviews on the RCH front lawn and not within the hospital. The only time media should be allowed into the hospital is when escorted by a RCH volunteer or public affairs staff to the press conference meeting room. Undertake the role of the Hospital Spokesperson in conjunction with the District Manager. OCCUPATIONAL HEALTH & SAFETY COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Manager Occupational Health and Safety District Occupational Health and Safety Officer DEM Resources Work Room Version 1.0 June 2007 Page 49 of 53

Duties The purpose of this position is to coordinate the Occupational Health and Safety and Emergency Management response to the Internal Emergency. Liaise with external Emergency Services (Queensland Police Service and Queensland Fire and Rescue Service) to coordinate the response required. Provide MSDS details via the CHEMALERT system. Provide air monitoring assessments as required. Liaise with Engineering and Building Services on works required. Provide hygiene and environmental assessments as required. Provide advice to maintain fire safety throughout the duration of the Internal Emergency. BUILDING COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Asset Manager Buildings and Plant Director Engineering and Building Services RBWH DEM Resources Work Room Version 1.0 June 2007 Page 50 of 53

Duties The purpose of this position is to coordinate the engineering response to the Internal Emergency. Provide specialist advice on building and plant components affected as a result of the Internal Emergency. Coordinate the repairs or replacement of specific building and/or plant items affected by the Internal Emergency. Liaise with external contractors to determine repair options and likely implications to the hospital environment. Provide specialist documentation from the Built Environment Materials Information Register (BEMIR) to assist internal and external officers in the repair or replacement of specific building and/or plant items. INFORMATION TECHNOLOGY COORDINATOR DESIGNATED PERSON: ALTERNATE PERSON: LOCATION: Manager Information & Technology Services Principal District Electronic Publisher DEM Resources Work Room Version 1.0 June 2007 Page 51 of 53

Duties The purpose of this position is to provide specialist advice to maintain ICT Infrastructure (networks etc) during an Internal Emergency. Liaise with the Command Post Coordinator on the status of the Internal Emergency. Determine the status of critical ICT Infrastructure within the area/s affected by the Internal Emergency. Advise the Command Group on the course of action to undertake to minimize disruption to the ICT Infrastructure. Advise the Command Group on alternatives in the event that ICT Infrastructure are lost as a result of the internal Emergency. Liaise with the Departmental Managers of the affected area/s to provide expert advice on the current status and actions to undertake to minimize disruption to their services. SECTION 10: SITE PLAN Version 1.0 June 2007 Page 52 of 53

FIRE EVACUATION ASSEMBLY POINTS EVACUATION SHOULD BE SIDEWAYS THROUGH THE BUILDINGS UNLESS OTHERWISE ADVISED ASSEMBLY POINT 1 ASSEMBLY POINT 2 ASSEMBLY POINT 3 ASSEMBLY POINT 4 ASSEMBLY POINT 5 ASSEMBLY POINT 6 MEDICAL SCHOOL PARK DRAGON SMOKERS AREA OUTSIDE QRI ENGINEERING SERVICES CARPARK AREA 26 FIRE DEMONSTRATION AREA GRASS AREA NURSE REC HALL Version 1.0 June 2007 Page 53 of 53